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Patient Safety Tip of the Week

February 15, 2022

Wrong-Side Chest Tubes

 

 

Anderson et al. recently published an excellent comprehensive review on chest tube management (Anderson 2022). But they omitted a key essential step – ensuring that the chest tube will be inserted on the correct side. In the early 1990’s, wrong-side chest tube insertion was one of the leading “wrong site” procedures in our New York Patient Occurrence Reporting and Tracking System (NYPORTS). Failure to perform the same sort of timeout and verification process that we use in the OR is a major reason that we still see wrong-side chest tube insertions.

 

In our July 2014 What's New in the Patient Safety World column “Wrong-Sided Thoracenteses” we noted some factors identified from wrong-side thoracenteses that would likely also contribute to wrong-side chest tube insertions. Miller et al. (Miller 2014) reported on 14 cases of thoracenteses performed on the wrong side outside the OR setting. A resident performed the procedure in 10 of the cases and an attending performed 2. An attending was present in 6 cases and a nurse was present in just 3 cases.

 

The most frequent associated factor was failure to perform a timeout (12 of the 14 cases). Laterality was missing from the consent form in 10 cases and the site was not marked in 12 cases. Medical image verification was not done in 7 of the 10 cases where information was available.

 

They found 30 root causes in the 14 cases (average 2.1 root causes per event). These most often included communication issues, failure to follow policy or procedures, and equipment issues. In several cases, the images were not available at the time of the procedure. That is particularly problematic in today’s computerized environment. If the PACS system is down, you may not have immediate access to the images. In the old days we’d bring the actual films with us to the bedside. Today there are no films, only the images on the computer system.

 

The authors also note that right-left confusion is a common human error in many scenarios. They note one resident knew the pleural effusion was on the left side on the x-ray but when he went behind the patient the x-ray image in his mind reversed.

 

Miller et al. note a number of strategies that are helpful in preventing such events. First is formal standardization of Universal Protocol and timeouts for invasive procedures anywhere, not just in the OR. Checklists, site marking, and ultrasound localization are also useful. Learning and practicing the procedures in a simulation environment is also encouraged. Development of a culture of patient safety and good communication is also critical.

 

While education, training, and simulation are all important, our own approach would incorporate forcing functions or constraints, which are much more effective interventions in most solutions. There are two good ways to ensure that a timeout gets done and force all the appropriate elements to prevent a wrong-site, wrong-side, or wrong-patient procedure. One is to prevent a physician from accessing the procedure tray all alone. That is best done by requiring an order for the tray, which would require a nurse to access the tray and accompany the physician to the patient’s room (or other site where the procedure will be performed) and participate in the timeout and the procedure. Second is to include on the outside of the sterile procedure tray a checklist that must be completed prior to opening the sterile tray. That checklist, of course, would include the items typically in the Universal Protocol and timeouts (things like consent, verification of the patient, procedure, laterality including review of relevant imaging studies, etc.).

 

That approach is borne out by another study (Barsuk 2011) that looked at lumbar punctures, thoracenteses and paracenteses done on the medicine services at their facilities (see our June 6, 2011 Patient Safety Tip of the Week “Timeouts Outside the OR”). Analyzing their processes, they found that staff were often unaware of Universal Protocol (or perhaps unaware that it was required not just for OR procedures, but for bedside procedures as well) and that nurses were frequently never notified by physicians when their patients were undergoing such procedures. In their redesigned process the physician initiates the process by entering an order via CPOE with an anticipated time. This order would automatically populate the nurse’s alert list and provide the nurse with a timeout form and notice of a procedure-specific supply kit to procure. Only the nurse has a key to those procedure kits. This is a forcing function that forces the physician-nurse communication to take place. The nurse brings the timeout checklist and the kit to the bedside at the specified time and the nurse and physician go through the timeout procedure, which gets documented in the EMR. Compliance with Universal Protocol went from 16% before to 94% after implementation of this redesigned process.

 

Good chest tube management includes all the elements elegantly outlined by Anderson et al., but also begins by including these important steps prior to breaking the seal on the procedure kit.

 

 

Some of our prior columns related to wrong-site surgery:

  September 23, 2008 “Checklists and Wrong Site Surgery”

  June 5, 2007              “Patient Safety in Ambulatory Surgery”

  July 2007                  “Pennsylvania PSA: Preventing Wrong-Site Surgery”

  March 11, 2008         “Lessons from Ophthalmology”

  July 1, 2008              “WHO’s New Surgical Safety Checklist”

  January 20, 2009       “The WHO Surgical Safety Checklist Delivers the Outcomes”  

  September 14, 2010 “Wrong-Site Craniotomy: Lessons Learned”

  November 25, 2008 “Wrong-Site Neurosurgery”

  January 19, 2010       “Timeouts and Safe Surgery”

  June 8, 2010              “Surgical Safety Checklist for Cataract Surgery”

  December 6, 2010     “More Tips to Prevent Wrong-Site Surgery”

  June 6, 2011              “Timeouts Outside the OR”

  August 2011             “New Wrong-Site Surgery Resources”

  December 2011         “Novel Technique to Prevent Wrong Level Spine Surgery”

  October 30, 2012      “Surgical Scheduling Errors”

  January 2013             “How Frequent are Surgical Never Events?”

  January 1, 2013         “Don’t Throw Away Those View Boxes Yet”

  August 27, 2013       “Lessons on Wrong-Site Surgery”

  September 10, 2013 “Informed Consent and Wrong-Site Surgery”

  July 2014                  “Wrong-Sided Thoracenteses”

  March 15, 2016         “Dental Patient Safety”

  May 17, 2016            “Patient Safety Issues in Cataract Surgery”

  July 19, 2016            “Infants and Wrong Site Surgery”

  September 13, 2016 “Vanderbilt’s Electronic Procedural Timeout”

  May 2017                  “Another Success for the Safe Surgery Checklist”

  May 2, 2017              “Anatomy of a Wrong Procedure”

  June 2017                  “Another Way to Verify Checklist Compliance”

  March 26, 2019         “Patient Misidentification”

  May 14, 2019            “Wrong-Site Surgery and Difficult-to-Mark Sites”

  May 2020                  “Poor Timeout Compliance: Ring a Bell?”

  September 14, 2021 “Wrong Eye Injections”

  October 5, 2021        “Wrong Side Again”

  November 9, 2021    “Ensuring Safe Site Surgery”

 

 

References:

 

 

Anderson D, Chen SA, Godoy LA, et al. Comprehensive Review of Chest Tube Management: A Review. JAMA Surg 2022; Published online January 26, 2022

https://jamanetwork.com/journals/jamasurgery/fullarticle/2788397

 

 

Miller KE, Mims M, Paull DE, et al. Wrong-Side Thoracentesis: Lessons Learned From Root Cause Analysis. JAMA Surg. 2014; 149(8): 774-779

https://jamanetwork.com/journals/jamasurgery/fullarticle/1879844

 

 

Barsuk JH, Brake H, Caprio T, Barnard C, Anderson DY, Williams MV. Process Changes to Increase Compliance With the Universal Protocol for Bedside Procedures. Arch Intern Med. 2011; 171(10): 941-954

https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/487053

 

 

 

 

 

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